Several epidemiological studies have shown the presence of comorbidity between various types of sleep disorders and different headache subtypes. Migraine without aura is a sensitive risk factor for disorders of initiating and maintaining sleep (odds ratio (OR) 8.2500), and chronic tension-type headache for sleep breathing disorders (OR 15.231), but headache disorder is a cumulative risk factor for disorders of excessive somnolence (OR 15.061). This result has not been reported in the clinical literature. © Springer-Verlag Italia 2005

CAROTENUTO M

GALLI, FEDERICA

GUIDETTI, Vincenzo

PASCOTTO A.

RUJU F

TAGLIENTE F. R

GALLI F

PASCOTTO A

TAGLIENTE F.

Archivio della ricerca- Università di Roma La Sapienza

Headache disorders as risk factors for sleep disturbances in school-aged children.

IntroductionSeveral epidemiological studies have shown the presenceof comorbidity between various types of sleep disordersand different headache subtypes. Headaches and sleep dis-turbances are two of the most common and ubiquitous dis-orders faced in clinical practice. Frequently encounteredin the same patient, the two complaints may have a rela-tionship that is often unclear.Many different sleep disorders, including circadianrhythm disorders, are associated with headache [1].Inadequate sleep duration or poor sleep quality are com-mon triggering factors for migraine headaches.There have been several observations of the co-occur-rence of sleep disturbances and headaches in children [2,3]. In fact, sleep disturbances and migraine are part of acluster of recurrent clinical symptoms that make up whathas been called the periodic syndrome of childhood.It has been proposed that sleep and migraine may beaspects of a common genetic, pathophysiological orbiobehavioural substrate, accounting for the comorbidityof these problems in children. However, while a relation-ship between migraine headaches and sleep disturbancesJ Headache Pain (2005) 6:268–270DOI 10.1007/s10194-005-0204-zHeadache disorders as risk factors for sleepdisturbances in school aged childrenH E A D A C H E  I N  C H I L D H O O D  A N D  A D O L E S C E N C EM. Carotenuto ()Dipartimento di Psichiatria, Neuropsichiatria infantile, Audiofoniatria,Dermatovenereologia,Cattedra di Neuropsichiatria Infantile,Via Pansini 5 PAD XI, I-80131 Naples, Italye-mail: marco.carotenuto@unina2.itTel.: +39-081-5666692 M. Carotenuto • F. Ruju • A. PascottoDepartment of Developmental Neurologyand Psychiatry,Second University of Naples, Naples, ItalyV. Guidetti • F. Galli • F.R. TaglienteDepartment of Developmental Neurologyand Psychiatry,University of Rome “La Sapienza”, Rome, ItalyMarco CarotenutoVincenzo GuidettiFrancesca RujuFederica GalliFrancesca R. TaglienteAntonio PascottoAbstract Several epidemiologicalstudies have shown the presence ofcomorbidity between various typesof sleep disorders and differentheadache subtypes. Migraine with-out aura is a sensitive risk factor fordisorders of initiating and maintain-ing sleep (odds ratio (OR) 8.2500),and chronic tension-type headachefor sleep breathing disorders (OR15.231), but headache disorder is acumulative risk factor for disordersof excessive somnolence (OR15.061). This result has not beenreported in the clinical literature.Key words Sleep • Excessive diur-nal sleepiness • Headaches • SleepDisturbances Scale for ChildrenPublished online: 20 July 2005269has been found in adults, research with paediatric popula-tions remains limited [4].The serotonergic system, well known as being centralin migraine attacks, demonstrates circadian and circannu-al rhythmicity and is, like other biorhythms, under thepacemaker control of the CNS. Herein, during the onset ofa migraine attack, the urinary excretion of 5-hydroxyin-doleacetic acid (5-HIAA), which is the main metabolite ofserotonin, increases and platelet 5-HT decreases rapidly;pharmacologic depletion can induce a migraine attack,and intravenous 5-HT can abort acute migraine attacks.Systemic serotonin also decreases during REM sleepwhen the dorsal raphe is silent, which may account in partfor the relationship between REM sleep and migraine. Inaddition to the clinical association between headache andsleep, their relationship also hinges on whether there is arelationship between the hypothalamus (and other regionscrucial to the regulation of sleep) and those areas involvedin nociception and migraine pathogenesis, suggesting thatdysfunction in the regulation of the sleep-regulating sys-tem must be capable of generating headaches.Children with migraine headaches appear to have arange of sleep disturbances. Insufficient sleep, bruxismand co-sleeping are common. Consistent with priorresearch, children with migraine experienced significantlymore frequent sleep disturbances compared to childrenfrom a normative community sample [5]. Children withmigraine experienced greater sleep disturbances in alldomains including longer sleep onset delay, more bedtimeresistance, shorter sleep duration, more daytime sleepi-ness, more night wakings, greater sleep anxiety, moreparasomnias and more sleep-disordered breathing.Although the mechanism by which sleep deprivationor sleep disruption leads to headache is unknown, theassociation has been recognised for decades. Dull, frontal-aching headaches will develop both in normal subjectsand in those who suffer from tension-type headaches whoare deprived of sleep [6].In a recent prospective longitudinal study examiningthe temporal relationships between daily stress, sleep andheadache using time-series analysis with lagged correla-tions, Penzien and colleagues found that altered sleep pat-terns played a key role in precipitating or exacerbatingrecurrent headache [7].The aim of this study is to assess the odds ratio (OR)of developing sleep disorders in school-aged children withheadache.MethodsOne hundred and seventy children aged 5–10 years (mean age 8.12,SD±1.44) referred between January 2004 and May 2005 to universi-ty third level headache centres in Naples and Rome were studied withthe Sleep Disturbance Scale for Children questionnaire (SDSC) [8] toassess sleep habits, and were compared with 170 matched children.The SDSC consists of 26 items and is composed of 6 sleepdisorder subscales: disorders in initiating and maintaining sleep(DIMS), sleep breathing disorders (SBD), disorders of arousal(DA), sleep-wake transition disorders (SWTD), disorders ofexcessive somnolence (DES) and nocturnal hyperhydrosis(SHY). The SDSC subscales are congruent to the InternationalClassification of Sleep Disorders [9].Children were selected according to the IHS 2004 criteria,and absence of other neurological or psychiatric disorders(epilepsy, behavioural problems, ADHD, neuromuscular dis-eases), and were evaluated by clinical interview and examinationas well by neurophysiological recordings (wake and sleep EEG).Children were excluded from the study if they had known clini-cal conditions such as Down’s syndrome or craniofacial abnor-malities. None of the recruited children were being treated withanticonvulsant or psychoactive drugs.ResultsGlobal frequency headache subgroups are: migraine withaura (MA) 20%, migraine without aura (MO) 38.24%,episodic tension-type headache (ETTH) 19.41% andchronic tension-type headache (CTTH) 22.35%.Headache children showed higher scores of DIMS,SBD, DA, SWTD and DES categories while lower SHYTable 1 Mean scores and standard error of items evaluated with the Sleep Disturbance Scale for Children testHeadache Normal F pSleep latency 17.20±4.5 17.08±4.6 1.06 0.66Nocturnal sleep 476.47±96.52 531.52±81 1.39 0.03DIMS 11.60±4.1 10.68±3.06 1.79 <0.0001SBD 5.34±3.39 4.07±1.76 3.68 <0.0001DA 4.35±2.11 3.75±1.04 1.57 <0.0001SWTD 10.4±3.38 8.82±3.62 1.14 0.36DES 9.77±3.11 6.74±2.25 1.91 <0.0001SHY 2.5±0.93 2.88±1.6 2.94 <0.001270scores were observed (Table 1). Nocturnal sleep duration(in minutes) is lower in the headache group (headachegroup 476.47±96.52, normal 531.52±81, p=0.03).No differences were observed for Sleep Latency(headache children 17.20±4.5, normal 17.08±4.6,p=0.66). To assess the OR for a single headache subgroup,a logistic regression analysis was performed: MO is a sen-sible risk factor for DIMS (OR 8.25), and CTTH for SBD(OR 15.231), but headache disorder is a cumulative riskfactor for DES (OR 15.061). This result has not beenreported in the clinical literature.ConclusionsSeveral studies on headache in children outlined thecomorbidity of headaches and sleep disorders and also arelationship between sleep breathing disorders andmigraine or tension-type headache. Few studies havefocused on the whole sleep-wake cycle and on the circa-dian aspects of headache to clarify the close relationshipbetween them, even though clinical evidence suggests theimportance of investigating sleep habits in paediatricheadache centres.References1. Sahota PK, Dexter JD (1990) Sleepand headache syndromes: a clinicalreview. Headache 30:80–842. Lanzi G, Balottin U, Fazzi E, RosanoFB (1983) The periodic syndrome inpediatric migraine sufferers.Cephalalgia 3:218–2203. Lanzi G, Zambrino CA, Balottin U,Tagliasacchi M, Vercelli P, Termine C(1997) Periodic syndrome andmigraine in children and adolescents.Ital J Neurol Sci 18:283–2884. Paiva T, Martins P, Batista A,Esperanca P, Martins I (1994) Sleepdisturbances in chronic headachepatients: a comparison with healthycontrols. Headache 5:135–1415. Bruni O, Fabrizi P, Ottaviano S,Cortesi F, Giannotti F, Guidetti V(1997) Prevalence of sleep disorders inchildhood and adolescence withheadache: a case-control study.Cephalalgia 17:492–4986. Blau JN (1990) Sleep deprivationheadache. Cephalalgia 10:157–1607. Penzien DB, Rains JC, Andrew ME,Galovski TE, Mohammed Y, MosleyTH (2001) Relationships of dailystress, sleep, and headache: a time-series analysis. Cephalalgia21:262–263 (Abstract)8. Bruni O, Ottaviano S, Guidetti V et al(1996) The Sleep Disturbance Scale forChildren (SDSC). Construction andvalidation of an instrument to evaluatesleep disturbances in childhood andadolescence. J Sleep Res 5:251–2619. – (1990) International Classification ofSleep Disorders. Diagnostic andCoding Manual. American SleepDisorders Association, Rochester, MN

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Headache disorders as risk factors for sleep disturbances in school aged children.

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Headache disorders as risk factors for sleep disturbances in school-aged children.

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Archivio della ricerca- Università di Roma La Sapienza

Archivio della ricerca- Università di Roma La Sapienza